NORTH CAROLINA MEDICAID DENTAL PROGRAM UPDATE July 16, 2008 2008 Statewide Oral Health Conference.

NORTH CAROLINA NORTH CAROLINA MEDICAIDMEDICAID

DENTAL PROGRAM DENTAL PROGRAM UPDATEUPDATE

July 16, 2008July 16, 20082008 Statewide Oral Health 2008 Statewide Oral Health

ConferenceConference

Objectives of PresentationObjectives of Presentation

Discussion of budgetary trends including latest strategies for Discussion of budgetary trends including latest strategies for reimbursement rate increasesreimbursement rate increases

Discussion of policy initiatives – recently implemented, in Discussion of policy initiatives – recently implemented, in progress and planned for the futureprogress and planned for the future

Discussion of access to care measurements – methodologies, Discussion of access to care measurements – methodologies, recent DMA NC county data and trends in datarecent DMA NC county data and trends in data

Brief introduction to documentation for the purposes of Brief introduction to documentation for the purposes of payment by third party payers – Federal OIG’s “Report on payment by third party payers – Federal OIG’s “Report on Improper Payments for Medicaid Pediatric Dental ServicesImproper Payments for Medicaid Pediatric Dental Services

MEDICAID DENTAL MEDICAID DENTAL EXPENDITURESEXPENDITURES

Increases in expenditures each year from SFY 1990 – SFY Increases in expenditures each year from SFY 1990 – SFY 2007 ($16.8 million to $240 million)2007 ($16.8 million to $240 million)

SFY 2008 targeting total expenditures at approx. $270 SFY 2008 targeting total expenditures at approx. $270 million after 11 months of the SFY. Over SFY 2007, SFY million after 11 months of the SFY. Over SFY 2007, SFY 2008 expenditures up almost 11% and total number of 2008 expenditures up almost 11% and total number of recips receiving services up 8% recips receiving services up 8%

Dental Program share of Total Medicaid Expenditures has Dental Program share of Total Medicaid Expenditures has grown from 1.2% in SFY 1990 to over 2.5% in SFY 2007grown from 1.2% in SFY 1990 to over 2.5% in SFY 2007

In terms of % growth in expenditures from SFY 2003 to SFY In terms of % growth in expenditures from SFY 2003 to SFY 2007 dental expenditures ranked second at 86% over the 2007 dental expenditures ranked second at 86% over the five year period – ahead of physician services, inpatient five year period – ahead of physician services, inpatient hospital services and mental health clinic services. Only hospital services and mental health clinic services. Only trails non-physician practitioner services- includes trails non-physician practitioner services- includes COMMUNITY SUPPORT!COMMUNITY SUPPORT!

MEDICAID SERVICES MEDICAID SERVICES EXPENDITURES SFY 2006EXPENDITURES SFY 2006

Medicare Premiums, 3.4 %

Clinics, 7.0%

ICF-MR, 4.8%

Prescription Drugs, 16.1%

Home Health, 2.5%

All Other Services, 13.6%

Inpatient Hospital, 11.9%

Outpatient Hospital, 7.0%

Mental Hospital >65 & <21, 0.5%

Physician Services, 9.5%

HMO Premiums, 1.4%

Personal Care Services, 5.4%

Dental,2.5%

Nursing Facilities, 12.7%

Growth in Dental Program from SFY 1990 - Growth in Dental Program from SFY 1990 - SFY 2006SFY 2006

(% of Total Medicaid Program Expenditures)(% of Total Medicaid Program Expenditures)

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%S

FY

199

0

SF

Y 1

992

SF

Y 1

994

SF

Y 1

996

SF

Y 1

998

SF

Y 2

000

SF

Y 2

002

SF

Y 2

004

SF

Y 2

006

Total Dental ExpendituresTotal Dental ExpendituresSFY 1990 – SFY 2007SFY 1990 – SFY 2007

$0.00

$50.00

$100.00

$150.00

$200.00

$250.00

$300.00

SFY 199

0

SFY 199

2

SFY 199

4

SFY 199

6

SFY 199

8

SFY 200

0

SFY 200

2

SFY 200

4

SFY 200

6

SFY

mil

lio

n $

Top Ten ProceduresTop Ten Procedures(ranked by total cost to Medicaid)(ranked by total cost to Medicaid)

Reimbursement Rate ComparisonsReimbursement Rate ComparisonsProcedureProcedure Actual NC Actual NC

Medicaid Medicaid Rate 2007Rate 2007

NDAS Median NDAS Median 2007 2007

(market-(market-based based

benchmark)benchmark)

Current % Current %

of NDAS of NDAS MedianMedian

Total Total ExpendituresExpenditures

SFY 2007SFY 2007

Two surface Two surface composite filling – composite filling – posterior toothposterior tooth

$116.07$116.07 $175.00$175.00 66%66% $20,494,674.02$20,494,674.02

One surface One surface composite filling – composite filling – posterior toothposterior tooth

$77.38$77.38 $133.00$133.00 58%58% $17,116,883.75$17,116,883.75

Sealant per toothSealant per tooth $29.93$29.93 $41.00$41.00 73%73% $14,451,740.57$14,451,740.57

Comprehensive Oral Comprehensive Oral Exam -- new patientExam -- new patient

$45.00$45.00 $64.00$64.00 70%70% $10,350,373.69$10,350,373.69

Extraction erupted Extraction erupted toothtooth

$57.50$57.50$121.00$121.00

48%48% $9,566,921.39$9,566,921.39

Stainless Steel Crown, Stainless Steel Crown, primary toothprimary tooth

$144.25$144.25 $207.00$207.00 70%70% $9,366,040.04$9,366,040.04

Periodic Oral ExamPeriodic Oral Exam $27.01$27.01 $37.00$37.00 73%73% $9,143,127.59$9,143,127.59

Surgical Extraction –Surgical Extraction –erupted tootherupted tooth

$100.00$100.00 $208.00$208.00 48%48% $8,740,350.19$8,740,350.19

Three surface Three surface composite filling – composite filling – posteriorposterior

$149.70$149.70 $218.00$218.00 69%69% $8,466,225.37$8,466,225.37

Panoramic radiographPanoramic radiograph $57.67$57.67 $85.00$85.00 68%68% $7,191,098.72$7,191,098.72

Reimbursement Rates Reimbursement Rates

Overhead expenses for an average dental office are Overhead expenses for an average dental office are approximately 65% of collections -- procedures reimbursed approximately 65% of collections -- procedures reimbursed below 65% of NDAS benchmark means provider loses moneybelow 65% of NDAS benchmark means provider loses money

Adult services (denture, oral surgery, endodontic and Adult services (denture, oral surgery, endodontic and periodontal) still lag behind -- many of these procedures are periodontal) still lag behind -- many of these procedures are at or near the current floor below 50% of the 2007 NDAS at or near the current floor below 50% of the 2007 NDAS medianmedian Increasing these rates should attract more specialists Increasing these rates should attract more specialists

(oral surgeons, orthodontists, endodontists and (oral surgeons, orthodontists, endodontists and periodontists) to enroll in Medicaidperiodontists) to enroll in Medicaid

Many preventive and diagnostic services are reimbursed at Many preventive and diagnostic services are reimbursed at higher rates well above 60% of NDAS benchmark median – higher rates well above 60% of NDAS benchmark median – increased utilization of these services should lead to cost increased utilization of these services should lead to cost savings to the Medicaid program in the future savings to the Medicaid program in the future

Reimbursement RatesReimbursement Rates

Top ten procedures in total cost to NC Top ten procedures in total cost to NC Medicaid average at 64% of 2007 NDAS Medicaid average at 64% of 2007 NDAS (National Dental Advisory Service) (National Dental Advisory Service) benchmarkbenchmark

Top ten procedures in total cost account for Top ten procedures in total cost account for roughly 48% of overall dental expenditures roughly 48% of overall dental expenditures

2003 lawsuit settlement increasing 2003 lawsuit settlement increasing reimbursement for 37 procedural codes has reimbursement for 37 procedural codes has improved reimbursement rates for children’s improved reimbursement rates for children’s services services

Weighted average for all 200+ covered Weighted average for all 200+ covered services is approx. 62%services is approx. 62%

Reimbursement RatesReimbursement Rates

More needs to be done to increase reimbursement rates with a More needs to be done to increase reimbursement rates with a target goal of 75-80% of NDAS median, but progress has been target goal of 75-80% of NDAS median, but progress has been made over the last five yearsmade over the last five years

Increases in reimbursement rates to reflect prevailing market Increases in reimbursement rates to reflect prevailing market rates should be sustained by annual rate increases to match the rates should be sustained by annual rate increases to match the Dental CPI of 4.9% per year. Dental CPI of 4.9% per year.

Increasing rates will create a “Field of Dreams” effect – “Build it Increasing rates will create a “Field of Dreams” effect – “Build it and maintain it and they will come and remain active” – provider and maintain it and they will come and remain active” – provider enrollment will increaseenrollment will increase Examples – Indiana (1998), South Carolina (2000), Alabama Examples – Indiana (1998), South Carolina (2000), Alabama

(2000), Tennessee (2002), North Carolina (2003), Virginia (2000), Tennessee (2002), North Carolina (2003), Virginia (2005) (2005)

Strategies to Increase Strategies to Increase Reimbursement RatesReimbursement Rates

The NCGA has included a special provision in the The NCGA has included a special provision in the State Budget to increase Medicaid dental State Budget to increase Medicaid dental reimbursement rates $ 5 million in state approps – reimbursement rates $ 5 million in state approps – recurring funding over the next two SFYs.recurring funding over the next two SFYs.

With FMAP and county share this means a little less With FMAP and county share this means a little less than $15 million for rate increases or between 5-6% than $15 million for rate increases or between 5-6% of projected SFY 2008 dental budgetof projected SFY 2008 dental budget

Smaller increases make it harder to decide where Smaller increases make it harder to decide where the funding should be appliedthe funding should be applied

Some of the funding will be used to cover increases Some of the funding will be used to cover increases in inflation, consumption and increased numbers of in inflation, consumption and increased numbers of recipients receiving services due to rate increasesrecipients receiving services due to rate increases


Increase the floor from 48% of NDAS Increase the floor from 48% of NDAS medianmedian Pros: will increase rates for procedures that are Pros: will increase rates for procedures that are

furthest behind market based benchmarks furthest behind market based benchmarks (UCR) – oral surgery, removable pros, endo, (UCR) – oral surgery, removable pros, endo, perio, etc. – mostly adult services – at or near perio, etc. – mostly adult services – at or near the floor of 48% NDAS. the floor of 48% NDAS.

Cons: Cons: Will not address lawsuit settlement codes (children’s Will not address lawsuit settlement codes (children’s

services) – no increase in these codes since 2003services) – no increase in these codes since 2003 Will result in criticism from some circles in the Will result in criticism from some circles in the

provider communityprovider community


Targeted rate increasesTargeted rate increases Pros: allows increases in the rates for codes Pros: allows increases in the rates for codes

that program staff deem most worthy of that program staff deem most worthy of increase based on utilization and other increase based on utilization and other factorsfactors

Cons:Cons: May not raise the floor for many services that lag May not raise the floor for many services that lag

far behind market based benchmarksfar behind market based benchmarks Will result in criticism from some circles in the Will result in criticism from some circles in the

provider communityprovider community

Conclusions:Conclusions:Strategies to Increase Strategies to Increase Reimbursement RatesReimbursement Rates

““You can’t please all the people (providers) all the You can’t please all the people (providers) all the time” time”

DMA has employed forms of both strategies in the DMA has employed forms of both strategies in the last three rate increases since 9/2006.last three rate increases since 9/2006. ““Zigging and zagging” to address needs with limited Zigging and zagging” to address needs with limited

fundingfunding Kudos to NCGA for including rate increases in the Kudos to NCGA for including rate increases in the

budget and to organized dentistry for recent budget and to organized dentistry for recent successful lobbying efforts.successful lobbying efforts.

““Please, sir (and madam), can we have more?”Please, sir (and madam), can we have more?” We have come a long way since the lawsuit settlement We have come a long way since the lawsuit settlement

in 2003.in 2003.

Adoption of D0145Adoption of D0145

Why?Why? Promote the concept of the “dental home” Promote the concept of the “dental home”

by age 1by age 1 Encourage dentists to treat Medicaid Encourage dentists to treat Medicaid

preschool children and increase access to preschool children and increase access to oral health care for this group of recipients oral health care for this group of recipients

Link the oral evaluation code to the safest Link the oral evaluation code to the safest and most effective preventive technique and most effective preventive technique to reduce early childhood caries (ECC) – to reduce early childhood caries (ECC) – fluoride varnishfluoride varnish


What is it?What is it? D0145 – D0145 – oral evaluation for a patient oral evaluation for a patient

under three years of age and counseling under three years of age and counseling with primary caregiverwith primary caregiver

Preferably within first 6 months of the eruption of the Preferably within first 6 months of the eruption of the first primary toothfirst primary tooth

Includes:Includes: Recording the oral and physical health historyRecording the oral and physical health history Evaluation of caries susceptibility (assess risk for ECC)Evaluation of caries susceptibility (assess risk for ECC) Development of an appropriate preventive oral health Development of an appropriate preventive oral health

regimenregimen Communication with and counseling of the child’s Communication with and counseling of the child’s

parent(s)/guardian and/or primary caregiverparent(s)/guardian and/or primary caregiver


Who can render the service?Who can render the service? Dentist must complete the diagnostic Dentist must complete the diagnostic

oral evaluation and subsequent oral evaluation and subsequent treatment planningtreatment planning

RDHs, CDAs can complete delegable RDHs, CDAs can complete delegable tasks such as recording of oral and tasks such as recording of oral and physical health history, development of physical health history, development of an appropriate preventive oral health an appropriate preventive oral health regimen and portions of the evaluation regimen and portions of the evaluation of caries susceptibility.of caries susceptibility.

Adoption of D0145 Adoption of D0145 Claims/Billing InstructionsClaims/Billing Instructions

D0145 must be provided on the same date of service and billed in conjunction with D1206 (topical fluoride varnish); therapeutic application for moderate to high caries risk patients to receive payment for any claim including D0145.

Why? – evidence based research indicates that FV is the most effective and safest preventive technique in the battle against ECC

Adoption of D0145 Adoption of D0145 Claims/Billing InstructionsClaims/Billing Instructions

Other dental services (except other diagnostic and fluoride procedures) can be provided on the same date of service as the D0145 and D1206 diagnostic/preventive oral health service package..

At age 3 and older, only D0120 is At age 3 and older, only D0120 is allowed for periodic visits.allowed for periodic visits.

Claims/Billing InstructionsClaims/Billing Instructions

Flexibility allowed Flexibility allowed If providers do not wish to apply topical FV (D1206) to a If providers do not wish to apply topical FV (D1206) to a

patient under 3 years of age at a periodic visit, they may patient under 3 years of age at a periodic visit, they may still use procedural code D0120 to report and receive still use procedural code D0120 to report and receive reimbursement for the periodic oral evaluation rendered on reimbursement for the periodic oral evaluation rendered on that date of service. that date of service.

Any of the three diagnostic codes (D0120, D0145 or D0150) three diagnostic codes (D0120, D0145 or D0150) can be billed for the patient’s first visit. However, D0145 can be billed for the patient’s first visit. However, D0145 must be provided in conjunction with D1206 -- topical FV to must be provided in conjunction with D1206 -- topical FV to receive reimbursement for any claim with D0145 .receive reimbursement for any claim with D0145 .

For follow-up visits D0120 or D0145 can be rendered every For follow-up visits D0120 or D0145 can be rendered every 6 calendar months until age 3. (Again, D0145 must be 6 calendar months until age 3. (Again, D0145 must be provided with D1206 – topical FV)provided with D1206 – topical FV)

SamplePeriodicity Schedule for

Diagnostic and Preventive Services for Preschool Recipients

Age (months)Age (months) Procedures Procedures PerformedPerformed

6 D0150, D1206

12 D0145, D1206

18 D0145, D1206

24 D0145, D1206

30 D0145, D1206

Before 36 D0145, D1206

42 or older D0120, D1206

Policy Initiatives:Policy Initiatives:In ProgressIn Progress

D2393 – resin based composite -- three D2393 – resin based composite -- three surfaces, posterior – will eliminate policy limit surfaces, posterior – will eliminate policy limit and allow procedure on primary molars. and allow procedure on primary molars. Policy limit remains in effect on D2394.Policy limit remains in effect on D2394.

Considering changing the frequency interval Considering changing the frequency interval of D0145 – oral evaluation of a patient under of D0145 – oral evaluation of a patient under three years of age and D1206 – topical three years of age and D1206 – topical fluoride varnish application to allow as often fluoride varnish application to allow as often as every 4 months for preschool recipients as every 4 months for preschool recipients who are identified through caries risk who are identified through caries risk assessment as susceptible to ECC. assessment as susceptible to ECC.

Policy Initiatives:Policy Initiatives:Future PlansFuture Plans

(“That Vision Thing”)(“That Vision Thing”) Improve access for special care patientsImprove access for special care patients

Examine other modelsExamine other models Enhanced reimbursement – Florida, South CarolinaEnhanced reimbursement – Florida, South Carolina Adopt D9920 – behavior management, by report – Adopt D9920 – behavior management, by report –

Arizona, New MexicoArizona, New Mexico Training requirements for providers – pediatric residency, Training requirements for providers – pediatric residency,

GPR, geriatric fellowship, special care fellowship, AHEC or GPR, geriatric fellowship, special care fellowship, AHEC or UNC SOD course – limited to qualified providersUNC SOD course – limited to qualified providers

No prior approval for D9920, limitations of present MMIS No prior approval for D9920, limitations of present MMIS to prevent overutilization of code – how do we link to prevent overutilization of code – how do we link recipient medical diagnosis to eligibility to receive recipient medical diagnosis to eligibility to receive D9920 service?D9920 service?

Growth in Number of Billing Growth in Number of Billing ProvidersProviders

1450150015501600165017001750180018501900

UnduplicatedProviders

Growth in Number of Billing Growth in Number of Billing Providers Providers

0

200

400

600

800

1000

SFY2001

SFY2003

SFY2005

SFY2007

SignificantProviders >=$10,000

Enrolled Providers -- SFY Enrolled Providers -- SFY 2007 2007

1795 enrolled billing providers with at least one paid 1795 enrolled billing providers with at least one paid claim claim billing providers receive paymentbilling providers receive payment

Approx. 2000 enrolled attending providers with at Approx. 2000 enrolled attending providers with at least one paid claimleast one paid claim attending providers render treatmentattending providers render treatment

3939 active licensed dentists in NC at end of CY 3939 active licensed dentists in NC at end of CY 20072007

>50% of active licensed dentists in provider network>50% of active licensed dentists in provider network implications – more dentists participate in Medicaid than implications – more dentists participate in Medicaid than

typically reported in the media – does not sell papers nor typically reported in the media – does not sell papers nor does it necessarily help those who advocate for higher does it necessarily help those who advocate for higher reimbursement reimbursement

““those greedy dentists” may not be as bad as reportedthose greedy dentists” may not be as bad as reported

Access to Dental Care: Access to Dental Care: All RecipientsAll Recipients

YEARYEAR # ELIGIBLE RECIPIENTS# ELIGIBLE RECIPIENTS

# ELIGIBLE # ELIGIBLE UNDUPLICATED UNDUPLICATED

RECIPIENTS RECIPIENTS RECEIVING AT RECEIVING AT

LEAST ONE DENTALLEAST ONE DENTAL PROCEDUREPROCEDURE

PERCENT PERCENT RECEIVING RECEIVING

DENTAL DENTAL CARECARE

SFY 2001SFY 2001 1,124,1291,124,129 276,247276,247 25%25%

SFY 2002SFY 2002 1,264,3621,264,362 327,285327,285 26%26%

SFY 2003SFY 2003 1,459,2391,459,239 370,447370,447 25%25%

SFY 2004SFY 2004 1,522,5081,522,508 417,935417,935 28%28%

SFY 2005SFY 2005 1,570,6491,570,649 458,694458,694 29%29%

SFY 2006SFY 2006 1,643,2161,643,216 488,279488,279 30%30%

SFY 2007SFY 2007 1,681,0091,681,009 524,920524,920 31%31%

Access to Dental Care: < Access to Dental Care: < 21 21

YEARYEAR# MEDICAID # MEDICAID

ENROLLEDENROLLED CHILDREN CHILDREN <21<21

# ELIGIBLE # ELIGIBLE UNDUPLICATED UNDUPLICATED

CHILD RECIPIENTS CHILD RECIPIENTS RECEIVING AT LEAST RECEIVING AT LEAST

ONE DENTAL ONE DENTAL PROCEDUREPROCEDURE

PERCENT RECEIVING PERCENT RECEIVING DENTAL CAREDENTAL CARE

SFY 2001SFY 2001 750,563750,563 188,941188,941 25%25%

SFY 2002SFY 2002 780,846780,846 228,498228,498 29%29%

SFY 2003SFY 2003 819,202819,202 267,809267,809 33%33%

SFY 2004SFY 2004 858,750858,750 299,800299,800 35%35%

SFY 2005SFY 2005 891,305891,305 332,298332,298 37%37%

SFY 2006SFY 2006 939,708939,708 360,955360,955 38%38%

SFY 2007SFY 2007 984,530984,530 398,499398,499 40%40%

Access Measurements SFY Access Measurements SFY 2007 --2007 --

County Specific SnapshotsCounty Specific Snapshots DMA QEHO has calculated dental access DMA QEHO has calculated dental access

measurements for children < 21 and adults >=21 for measurements for children < 21 and adults >=21 for each NC countyeach NC county

Please see this data along with other interesting Please see this data along with other interesting demographic and health care data for each county demographic and health care data for each county at : at : www.dhhs.state.nc.us/dma/countyreports/countyreporwww.dhhs.state.nc.us/dma/countyreports/countyreports.htmlts.html

Why? – to enable policymakers and other Why? – to enable policymakers and other stakeholders a chance to examine and better stakeholders a chance to examine and better understand Medicaid data on the local levelunderstand Medicaid data on the local level


County Specific SnapshotsCounty Specific Snapshots Methodology for dental access measurements – same as Methodology for dental access measurements – same as

current CMS recommendations on the CMS 416 (line current CMS recommendations on the CMS 416 (line 12a/line 1)12a/line 1)

Numerator = # of Medicaid eligibles receiving any dental Numerator = # of Medicaid eligibles receiving any dental procedure (CDT code) for the reporting periodprocedure (CDT code) for the reporting period Implications – for NC this includes preschool kids receiving IMB Implications – for NC this includes preschool kids receiving IMB

services from PCPs and extendersservices from PCPs and extenders Controversial among some pediatric oral health policy experts Controversial among some pediatric oral health policy experts

– Federal EPSDT regs define dental services as those provided – Federal EPSDT regs define dental services as those provided by a dentist or under the supervision of a dentistby a dentist or under the supervision of a dentist

Are physicians permitted by state law to practice dentistry? Are physicians permitted by state law to practice dentistry? YES!YES!

Still, there are naysayers who believe that PCPs and extenders Still, there are naysayers who believe that PCPs and extenders are not an effective means of providing diagnostic and are not an effective means of providing diagnostic and preventive procedures and only fulfilling one piece of the preventive procedures and only fulfilling one piece of the EPSDT regs requirement for comprehensive dental services – EPSDT regs requirement for comprehensive dental services – “fragmented” care – should not be counted on line 12a“fragmented” care – should not be counted on line 12a


County Specific SnapshotsCounty Specific Snapshots Denominator = any Medicaid recipient eligible for Denominator = any Medicaid recipient eligible for

Medicaid dental services during the reporting yearMedicaid dental services during the reporting year Implications – any Medicaid recipient eligible for even one Implications – any Medicaid recipient eligible for even one

month is included in the access measurement for the year month is included in the access measurement for the year – no requirement for continuous enrollment– no requirement for continuous enrollment

Differs from other accepted access measures like HEDIS Differs from other accepted access measures like HEDIS ADV which require continuous enrollment (HEDIS = 11 out ADV which require continuous enrollment (HEDIS = 11 out of 12 months) – see handout for statewide HEDIS ADV of 12 months) – see handout for statewide HEDIS ADV results for CY 2006results for CY 2006

Lack of continuous enrollment requirement has dramatic Lack of continuous enrollment requirement has dramatic effect on Medicaid access measurements because of the effect on Medicaid access measurements because of the transient nature of Medicaid eligibility – ex. – in NC in SFY transient nature of Medicaid eligibility – ex. – in NC in SFY 2006 approx. 1.6 million recips eligible at any time during 2006 approx. 1.6 million recips eligible at any time during the year, but average monthly eligibility was 1.2 million. the year, but average monthly eligibility was 1.2 million.

Access Measurements SFY 2007 --Access Measurements SFY 2007 --

County SpecificCounty Specific SnapshotsSnapshotsTrendsTrends

Data is based on recipient county of residence, not on Data is based on recipient county of residence, not on where care is obtainedwhere care is obtained

Access for adults poorer than for childrenAccess for adults poorer than for children Some NE and SW rural and remote counties have access Some NE and SW rural and remote counties have access

measures well below state average for both age groups – measures well below state average for both age groups – Dare, Camden, Pasquotank, Swain, Currituck, Perquimans, Dare, Camden, Pasquotank, Swain, Currituck, Perquimans, Bertie and JacksonBertie and Jackson

Some urban counties with large numbers of active licensed Some urban counties with large numbers of active licensed dentists, enrolled Medicaid providers and Medicaid recips dentists, enrolled Medicaid providers and Medicaid recips are a little below the state average for children – are a little below the state average for children – Cumberland, Mecklenburg, New Hanover, Wake.Cumberland, Mecklenburg, New Hanover, Wake. The ratio of actively participating dentists:Medicaid recips is The ratio of actively participating dentists:Medicaid recips is

lowlow Some urban counties with the same elements are Some urban counties with the same elements are

significantly above the state average for children – significantly above the state average for children – Buncombe, Durham, Forsyth, GuilfordBuncombe, Durham, Forsyth, Guilford

Access Measurements SFY 2007 --Access Measurements SFY 2007 --

County SpecificCounty Specific SnapshotsSnapshotsTrends/AnalysisTrends/Analysis

Some of the counties with access well above the state Some of the counties with access well above the state average for children are not urban – Wilkes, Carteret, Craven, average for children are not urban – Wilkes, Carteret, Craven, Franklin, Hyde, Montgomery, Moore, Polk, Wayne, YanceyFranklin, Hyde, Montgomery, Moore, Polk, Wayne, Yancey

Analysis – What does it all mean?Analysis – What does it all mean? Not entirely accurate to state that urban access is better than Not entirely accurate to state that urban access is better than

rural for the underserved when referring strictly to Medicaid rural for the underserved when referring strictly to Medicaid recipientsrecipients

Still need to address access issues in remote NE and SW countiesStill need to address access issues in remote NE and SW counties Adult access is improving but slowly – strategies to improve?Adult access is improving but slowly – strategies to improve?

More training and incentives to providers to increased access for More training and incentives to providers to increased access for special care patientsspecial care patients

Key ingredients to success – not entirely clear and more detailed Key ingredients to success – not entirely clear and more detailed analysis is necessaryanalysis is necessary

Hypothesis: takes good teamwork between active public and private Hypothesis: takes good teamwork between active public and private providers to achieve success – only limited success without both sides providers to achieve success – only limited success without both sides pulling their weightpulling their weight

Documentation for Payment Documentation for Payment PurposesPurposes

Federal DHHS OIG’s “Report on Improper Payments for Federal DHHS OIG’s “Report on Improper Payments for Medicaid Pediatric Dental Services” Medicaid Pediatric Dental Services” www.oig.hhs.gov/oei/reports/oei-04-04-00210.pdfwww.oig.hhs.gov/oei/reports/oei-04-04-00210.pdf Released Released September 2007September 2007

NC one of five states examined for CY 2003 paymentsNC one of five states examined for CY 2003 payments Overall results of study – 31% of Medicaid pediatric dental Overall results of study – 31% of Medicaid pediatric dental

payments were found to be in error – services provided in payments were found to be in error – services provided in error estimated to be about $155 million, of that an error estimated to be about $155 million, of that an estimated $96 million came from the Fedsestimated $96 million came from the Feds 24% documentation errors that resulted in reviewers being 24% documentation errors that resulted in reviewers being

unable to determine that services were medically necessary unable to determine that services were medically necessary and/or billed appropriatelyand/or billed appropriately

7% did not meet billing requirements7% did not meet billing requirements 2% were medically unnecessary procedures2% were medically unnecessary procedures Exceeds 31% because some services had more than one error Exceeds 31% because some services had more than one error

http://www.oig.hhs.gov/oei/reports/oei-04-04-00210.pdf


Examples of documentation errorsExamples of documentation errors 6% -- undocumented errors –no record of the service in the 6% -- undocumented errors –no record of the service in the

patient’s chart or service was unsubstantiated by records patient’s chart or service was unsubstantiated by records submittedsubmitted

9% -- insufficient documentation to determine correct billing9% -- insufficient documentation to determine correct billing Restoration performed with no identification of surfaces restoredRestoration performed with no identification of surfaces restored Surgical removal of impacted tooth with no documentation Surgical removal of impacted tooth with no documentation

demonstrating type of removal demonstrating type of removal 13% -- insufficient documentation to determine medical 13% -- insufficient documentation to determine medical

necessity –necessity – SSC provided – documented in record, no supporting radiographSSC provided – documented in record, no supporting radiograph Procedure supported by an inconclusive or undiagnostic Procedure supported by an inconclusive or undiagnostic

radiographradiograph


7% billing errors – incorrect procedure 7% billing errors – incorrect procedure codes, services that were not billable codes, services that were not billable because they violated policy or statute, because they violated policy or statute, incorrect number of units, unbundled incorrect number of units, unbundled servicesservices Upcoding – providing a two surface restoration Upcoding – providing a two surface restoration

and billing for a four+ surface restorationand billing for a four+ surface restoration Downcoding – billing a non-surgical extraction Downcoding – billing a non-surgical extraction

when providing a surgical removal of a toothwhen providing a surgical removal of a tooth Not billable service – two orthodontic Not billable service – two orthodontic

adjustments in the same month violating policy adjustments in the same month violating policy limit on once per monthlimit on once per month


Criticism of OIG’s study aboundsCriticism of OIG’s study abounds OIG substantially overstated error rates -- truly improper OIG substantially overstated error rates -- truly improper

payment rates are probably about the same in Medicaid payment rates are probably about the same in Medicaid as in commercial insurance. as in commercial insurance.

The “medical necessity” standard is a difficult standard The “medical necessity” standard is a difficult standard to apply to dental records because dentistry, unlike to apply to dental records because dentistry, unlike medicine, does not employ ICD9 diagnostic codes – no medicine, does not employ ICD9 diagnostic codes – no standardization for billing purposes. Diagnoses can vary standardization for billing purposes. Diagnoses can vary depending on the clinician reviewing the patient records depending on the clinician reviewing the patient records and radiographs.and radiographs.

Nearly 5% of the claims categorized as “undocumented” Nearly 5% of the claims categorized as “undocumented” were records that were not reviewed because they were were records that were not reviewed because they were not provided by the subject dentists; most studies would not provided by the subject dentists; most studies would eliminate these from consideration – not the OIG! eliminate these from consideration – not the OIG!


Too strict in terms of requirements for Too strict in terms of requirements for documentationdocumentation

Taking a diagnostic radiograph prior to an SSC Taking a diagnostic radiograph prior to an SSC may be very difficult on a preschooler; may be very difficult on a preschooler; according to the OIG’s study guidelines according to the OIG’s study guidelines documenting necessity based on clinical documenting necessity based on clinical findings is not enoughfindings is not enough

Too strict in terms of what is considered an Too strict in terms of what is considered an errorerror

transcription errors are counted – ex. – DOS in transcription errors are counted – ex. – DOS in patient record does not match DOS on claim patient record does not match DOS on claim formform


Lessons Learned:Lessons Learned: CMS and States need to do more outreach to educate CMS and States need to do more outreach to educate

providers about the need for better documentation and providers about the need for better documentation and to ensure compliance with policies and State and to ensure compliance with policies and State and Federal statutes and regsFederal statutes and regs

CMS and States need to refine prepayment MMIS audits CMS and States need to refine prepayment MMIS audits and edits and develop better post-payment review and edits and develop better post-payment review techniques that ensure appropriate documentation is techniques that ensure appropriate documentation is occurring in the provider communityoccurring in the provider community

Providers should take the initiative to seek training and Providers should take the initiative to seek training and guidance from the State Medicaid agencies – these guidance from the State Medicaid agencies – these resources are available in NC from both DMA and EDS.resources are available in NC from both DMA and EDS.

Division of Medical AssistanceDivision of Medical AssistanceNC MedicaidNC Medicaid

Dental ProgramDental Program

www.ncdhhs.gov/dma/dental.htm

Mark W. Casey, DDS, MPHMark W. Casey, DDS, MPH

Dental DirectorDental Director

[email protected]@ncmail.net

919-855-4280919-855-4280

mailto:[email protected]

Date post:	18-Jan-2016
Category:	Documents
Upload:	bridget-day
View:	217 times
Download:	2 times

NORTH CAROLINA MEDICAID DENTAL PROGRAM UPDATE July 16, 2008 2008 Statewide Oral Health Conference.

Documents